Blue PPO PremierHealth Silver 4 (2 Free In-Network PCP Visits) – PPO
73% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,650 per person $3,650 per person |
| Out-of-pocket max | $7,250 per person $14,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | 20% coinsurance after deductible |
| Non-preferred Brand | 20% coinsurance after deductible |
| Specialty | 20% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $75 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://common.secure.azblue.com/SBC/GetSBC?ProductName=PPO%20PremierHealth%20Silver%204%20&Deductibles=3650&EffectiveDate=2024/01/01&ContractType=2.pdf |
| Drug and medication plan formulary | https://www.azblue.com/blueexchangeselect3tierformulary |
| Search doctor list | https://www.azblue.com/ppo |
